Provider Demographics
NPI:1073055489
Name:JACKIE'S ENTERPRISES INC
Entity Type:Organization
Organization Name:JACKIE'S ENTERPRISES INC
Other - Org Name:HER UNDERTHINGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JACKLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:KETO
Authorized Official - Suffix:
Authorized Official - Credentials:CFM
Authorized Official - Phone:518-869-1100
Mailing Address - Street 1:2080 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:GUILDERLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12084-9517
Mailing Address - Country:US
Mailing Address - Phone:518-869-1100
Mailing Address - Fax:518-869-1105
Practice Address - Street 1:210 CORNELIA ST
Practice Address - Street 2:SUITE 105
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2336
Practice Address - Country:US
Practice Address - Phone:518-869-1100
Practice Address - Fax:518-869-1105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-16
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies